    <div class="container">
      <div class="bg-putih">

        <div class="jdl-page">
          <?php echo isset($judul)?$judul:'<font color="#ccc">Judul Belum Diberikan</font>'; ?>
          <div class="clearfix"></div>
        </div>

        <?php echo form_open(uri_string(), array('class' => 'form-horizontal', 'role' => 'form', 'id' => 'form')); ?>
        <input type="hidden" name="KdPasien" value="<?php echo $data['KdPasien']; ?>">
        <div class="form-group">
          <label class="col-xs-2 control-label">Nama Pasien</label>
          <div class="col-xs-10">
            <input type="text" name="nama" value="<?php echo $data['Nama']; ?>" class="form-control input-sm" placeholder="">
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">Tanggal Lahir</label>
          <div class="col-xs-2">
            <input type="text" name="tanggal" id="tanggal" class="form-control input-sm" value="<?php echo id_date($data['TanggalLahir'],'short'); ?>">
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">Jenis Kelamin</label>
          <div class="col-xs-10">
            <?php if ($data['JKel'] === "L") : ?>
              <input type="radio" name="jk" value="L" checked />Laki-Laki
              <input type="radio" name="jk" value="P" />Perempuan
            <?php else : ?>
              <input type="radio" name="jk" value="L" />Laki-Laki
              <input type="radio" name="jk" value="P" checked />Perempuan
            <?php endif; ?>
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">No.Telp</label>
          <div class="col-xs-10">
            <input type="text" name="telp" value="<?php echo $data['Telp']; ?>" class="form-control input-sm" placeholder="">
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">Alamat</label>
          <div class="col-xs-10">
            <textarea name="almt" id="almt" class="form-control input-sm" rows="3"><?php echo $data['Alamat']; ?></textarea>
          </div>
        </div>
        <div class="form-group">
          <div class="col-xs-offset-2 col-xs-10">
            <button type="submit" class="btn btn-primary btn-sm">Perbaharui</button>
            <button type="reset" class="btn btn-default btn-sm">Kosongkan</button>
          </div>
        </div>
        <?php echo form_close(); ?>

        <div class="clearfix"></div>
      </div>
    </div> <!-- /container -->

    <script>
      $("#form").validate({
        rules: {
          nama: {
            required: true,
            minlength: 3
          },
          ket: {
            required: true         
          }
        }
      });
    </script>

    <script type="text/javascript">
      $(document).ready(function(){
        $('#tanggal').datepicker({
          dateFormat: "dd/mm/yy",
          changeMonth: true,
          changeYear: true
        });
      });
    </script>